An estimated 1.5 percent to 7.5 percent of children suffer from encopresis (fecal soiling). One of the most effective ways of treating encopresis is with Enhanced Toilet Training (ETT). ETT is twice as effective as intensive medical management alone at 3, 6, and 12-month follow-up when delivered by skilled and knowledgeable clinicians. We have successfully transformed ETT into an interactive internet intervention, a web program accessible by anyone with a computer and internet access. This program has been shown to have significant additive value to standard clinical care, and is based on a theoretical model we developed for therapeutic behavior change achieved through internet interventions. To date, this Internet intervention for pediatric encopresis has only been offered to individuals who are currently in treatment with a health care provider. In order to significantly increase its potential for wide-spread dissemination, a new clinical trial is proposed in which families can self-refer to the intervention. In addition, as adherence is often a significant issue with internet interventions, an enhanced condition involving a stepped care approach with graduated levels of support (automated email, personalized email, phone support) for different levels of non-adherence will be evaluated as part of a large, national, randomized clinical trial. We propose a four year project in which we will experimentally test the short and long term benefits of the intervention as compared to use of the system with a stepped care approach to enhance adherence and ultimately symptom improvement. A static, educational website will be used with the control group. Cost-benefit analyses will be evaluated and documented. We hypothesize that the pediatric encopresis internet intervention will be more effective than a static website at 6 weeks and 12 months post treatment in terms of encopretic symptom reduction (including fewer accidents, increased BMs in toilet, and increased trips to the bathroom), behavior change (measured by acceptable cleanout, laxatives, straining, toileting, and routine), and reduced costs (doctor visits, medication usage, missed school/work days, diapers used). We also predict that the stepped care version of the program, as compared to the standard program, will produce greater website utilization and thus improved behavior change and symptom reduction. While overall cost will likely be higher with stepped care, we expect cost-benefit analyses to show that this increased cost is acceptable for a certain segment of the population studied. Additional testing of our model for internet interventions will also be conducted. Relevance: Internet interventions can provide sophisticated and personalized treatment at low cost. This application plans to take a program for children with encopresis and evaluate how effective it is when offered "direct-to-consumers." It also attempts to increase success by integrating methods to improve adherence to the program. Findings from this study will have far reaching implications for the management of encopresis in particular and internet interventions in general.